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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E(T9'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:p (209), 466478l <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z,6/_l J� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui: <br /> County Ordinance No. 1862 sand the Rule nd Regulations of the San Joaquin Local Health District. <br /> 5 JOB ADDRESS/LOC ON 0 CENSUS TRACT <br /> Owner's Name 1`�u/a-,fa f`-PV <br /> Address City.Phone <br /> �� <br /> ' <br /> Contractor's Name License1'� � hone ���� ` <br /> i TYPE OF WORK (Check): NEW WELL. /-7 DEEPEN '/7 RECONDITION-1-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / J PUMP REPAIRPUMP REPLACEMENT /_ <br /> { Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Q <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal y <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical * .. Surface. Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> f'PUIMP-REPAIR:=," `° �".,""°./ Smote Wcirk Done `'""4wr` - -/ <br /> z .- <br /> E`DESiRUCTION OF WELL: Well Diameter _ F Approximate Depth <br /> Describe Material and Procedure ' <br /> I hereby agree to comply with all- laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> after completion of my`work on a new well., I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting.. the..well. in.use.... The above <br /> information is true to=the best ,of my.-knowledge and belief. I WILL CALL FOR A ,GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. , <br /> SIGNED ( , TITLE <br /> MDRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I <br /> p APPLICATION ACCEPTED BY <br /> DATE , <br /> ADDITIONAL COMMENTS: <br /> PHAS 11, G UT PHASE I INAL INSPECTIO <br /> INSPECTION BY INSPECTION BY - DATE <br /> v 5 <br /> E H 1426 Rev. 1-74 i' ` to/7t� ?M <br />